1. An extraordinary admission, driven by physiotherapists Gemma Arnold & Lizzie Webb

2. Lymphoedema is……. - is chronic swelling of a body part (usually limbs) caused by the accumulation of fluid and protein in the tissue spaces arising from congenital malformation of the lymphatic system, or damage to lymphatic vessels and/ or lymph nodes (International Society of Lymphology 2003) per definition and anatomical picture

3. Meet the patient

4. Treatment Goals

6. Severe congenital lymphoedema affecting entire body Face, trunk, arms, hands, legs, feet, scrotum.... Recurrent pleural and pericardial effusions that have required surgical drainage. Severe penile and scrotal deformity due to skin grafts and oedema Recurrent cellulitis of arms and legs Hypertension Recurrent chest infections, cough and wheeze Sleep apnoea ADHD Epilepsy Immunodeficiency Middle ear effusions causing conductive deafness Very poor exercise tolerance short stature, growth retardation Protein losing state Complex ++

7. Comorbidities Severe congenital lymphoedema affecting entire body Face, trunk, arms, hands, legs, feet, scrotum.... Severe penile and scrotal deformity due to skin grafts and oedema Very poor exercise tolerance Recurrent cellulitis of arms and legs Cognitive impairment Recurrent pleural and pericardial effusions that have required multiple surgical interventions

8. It’s all about the plumbing.....

10. Best Practice Lymphoedema Management Normally includes: Massage Exercise Skin care COMPRESSION ADL advice

11. ?

12. Two considerations 1.Risk related to shifting fluid from the legs had to be addressed by provision of medical supervision. 2.The patient lived 2.5 hours away in a regional town

13. A 2 week hospital admission was required to allow safe allied health treatment !!!!

14. First “hurdles” ( high jumps?) Admitting Doctor Admission Date

15. Lining up the ducks……. -Critical timelines to ensure minimum patient stay

16. Pre admission “hurdles” Medical supervision Pre admission X rays Liaison with Registrar Patient support Volunteer services CNC on ward Physiotherapy Book therapist time = 40 hours Order bandages ENABLE funding and supply of compression garments

17. Arranged around the patient’s Infusion schedule 21 st Birthday party Transport availability ……….and Christmas was looming!

18. Treatment 8 Days of leg compression bandaging and 3 days of arm compression bandaging occurred during an 11 day inpatient admission. James then visited twice weekly as an outpatient for bandaging for 2 weeks until he was fitted with new compression garments.

19. Right leg Left leg

20. Results Measuring results

21. Results PRE TREATMENTPOST TREATMENT

22. Patient Severity of oedema Co- morbidities Psychosocial Functional goals